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Comparative study of I.D.E.A.L. technique and transtibial technique in anterior cruciate ligament reconstruction
1
昆明医科大学第一附属医院运动医学科（昆明 650032）, Department of Sports Medicine, the First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P. R. China
1
昆明医科大学第一附属医院运动医学科（昆明 650032）, Department of Sports Medicine, the First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P. R. China
1
昆明医科大学第一附属医院运动医学科（昆明 650032）, Department of Sports Medicine, the First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P. R. China
1
昆明医科大学第一附属医院运动医学科（昆明 650032）, Department of Sports Medicine, the First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P. R. China
1
昆明医科大学第一附属医院运动医学科（昆明 650032）, Department of Sports Medicine, the First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P. R. China
1
昆明医科大学第一附属医院运动医学科（昆明 650032）, Department of Sports Medicine, the First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P. R. China
1
昆明医科大学第一附属医院运动医学科（昆明 650032）, Department of Sports Medicine, the First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P. R. China
王国梁，Email：
200301144@163.com
Received 2024 Feb 8; Accepted 2024 Jul 12; Revised 2024 Jul 3.
回顾分析2020年1月—2022年9月收治且符合选择标准的60例ACL损伤患者临床资料。患者均接受关节镜下自体肌腱重建ACL，术中股骨隧道定位采用I.D.E.A.L技术30例（I.D.E.A.L组）、TT技术30例（TT组）。两组患者年龄、性别、身体质量指数、致伤原因、损伤侧别、受伤至手术时间、合并软骨及半月板损伤构成比以及术前Lysholm评分、国际膝关节文献委员会（IKDC）评分、疼痛视觉模拟评分（VAS）、胫骨前移差值、Blumensaat角等基线资料比较，差异均无统计学意义（
P
>0.05）。记录住院时间、术后早/远期并发症发生情况，采用Lysholm评分、IKDC评分及VAS评分评价膝关节功能及疼痛程度，测量胫骨前移差值；MRI复查观察移植物愈合情况，并测量移植物股骨端、中段、胫骨端信噪比（signal to noise quotien，SNQ）值，以及膝关节Blumensaat角。计算胫骨前移差值以及Blumensaat角的手术前后差值（变化值）进行组间比较。
结果
术后两组切口均Ⅰ期愈合，住院时间组间差异无统计学意义（
P
>0.05）。患者均获随访，随访时间12～18个月，平均14.9个月。术后两组膝关节Lysholm评分、IKDC评分均较术前增加，VAS评分降低，其中TT组术后1周VAS评分与术前差异无统计学意义（
P
>0.05），其余评分两组组内与术前差异均有统计学意义（
P
<0.05）。术后随时间延长，两组上述评分均呈进一步改善趋势；Lysholm评分、VAS评分术后1周及1、3、6、12个月间差异均有统计学意义（
P
<0.05），IKDC评分仅术后1个月与术后1周差异有统计学意义（
P
<0.05）。术后1周I.D.E.A.L组膝关节Lysholm评分、IKDC评分高于TT组、VAS评分更低，差异均有统计学意义（
P
<0.05）；1、3、6、12个月两组间差异均无统计学意义（
P
>0.05）。术后12个月，两组胫骨前移差值均较术前降低（
P
<0.05）；且I.D.E.A.L组变化值高于TT组，差异有统计学意义（
P
<0.05）。 I.D.E.A.L组术后早、远期并发症发生率均低于TT组（
P
<0.05）。术后12个月MRI检查示两组膝关节移植物均生存良好，Blumensaat角均较术前降低（
P
<0.05），且I.D.E.A.L组Blumensaat角变化值以及移植物股骨端、中段、胫骨端SNQ值均高于TT组（
P
<0.05）。
To compare the effectiveness of I.D.E.A.L technique and transtibial (TT) technique in anterior cruciate ligament (ACL) reconstruction.
Methods
A clinical data of 60 patients with ACL injury, who were admitted and met the selection criteria between January 2020 and September 2022, was retrospectively analyzed. All patients underwent arthroscopic ACL reconstruction with autologous tendon. During operation, the femoral tunnel was prepared by using I.D.E.A.L technique in 30 cases (I.D.E.A.L group) and using TT technique in 30 cases (TT group). There was no significant difference in baseline data such as age, gender, body mass index, cause of injury, injured side, interval from injury to operation, constituent ratio of combined cartilage and meniscus injury, and preoperative Lysholm score, International Knee Documentation Committee (IKDC) score, visual analogue scale (VAS) score, anterior tibial translation difference, and Blumensaat angle between the two groups (
P
>0.05). The length of hospital stay and the occurrence of early and late complications were recorded. During follow-up, the Lysholm score, IKDC score, and VAS score were used to evaluate knee joint function and pain degree, and the anterior tibial translation difference was measured. MRI reexamination was performed to observe the healing of the graft, and the signal to noise quotient (SNQ) values of the femoral end, middle section, and tibial end of the graft, as well as the Blumensaat angle of the knee joint were measured. The differences in tibial anterior translation difference and Blumensaat angle before and after operation (change values) were calculated and compared between the two groups.
Results
The incisions in both groups healed by first intention after operation, and there was no significant difference in the length of hospital stay between the two groups (
P
>0.05). All patients were followed up 12-18 months, with an average of 14.9 months. The Lysholm score and IKDC score of the knee joint in both groups after operation increased when compared with those before operation, and the VAS score decreased. Compared to preoperative scores, except for the VAS score of the TT group at 1 week after operation (
P
>0.05), there were significant differences in all scores at different time points postoperatively in the two groups (
P
<0.05). The above scores in both groups showed a further improvement trend with the prolongation of time after operation. There were significant differences in Lysholm score and VAS score among 1 week, 1 month, 3 months, 6 months, and 12 months after operation in the two groups (
P
<0.05). The IKDC score of both groups at 1 month after operation was significantly different from that at 1 week after operation (
P
<0.05). At 1 week after operation, the Lysholm score and IKDC score in the I.D.E.A.L group were significantly higher than those in the TT group (
P
<0.05), and the VAS score was significantly lower (
P
<0.05); there was no significant difference between the two groups at 1, 3, 6, and 12 months after operation (
P
>0.05). At 12 months after operation, the anterior tibial translation differences in both groups were significantly lower than those before operation (
P
<0.05); and the change value in the I.D.E.A.L group was significantly higher than that in the TT group (
P
<0.05). The incidences of early and late complications in the I.D.E.A.L group were significantly lower than those in the TT group (
P
<0.05). At 12 months after operation, MRI examination showed that the grafts of the knee joint in both groups survived well, and the Blumensaat angles of both groups were significantly smaller than those before operation (
P
<0.05). The change value of the Blumensaat angle in the I.D.E.A.L group was significantly higher than that in the TT group (
P
<0.05). The SNQ values of the femoral end, middle section, and tibial end of the graft in the I.D.E.A.L group were significantly higher than those in the TT group (
P
<0.05).
Conclusion
The early effectiveness of ACL reconstruction by using the I.D.E.A.L technique is better, the knee joint is more stable, and the incidence of postoperative complication is lower. However, the maturity of the graft after reconstruction using the TT technique is higher.
2020年1月—2022年9月，共60例患者符合选择标准纳入研究。关节镜下ACL重建术中股骨隧道定位采用I.D.E.A.L技术30例（I.D.E.A.L组）、TT技术30例（TT组）。两组患者年龄、性别、身体质量指数、致伤原因、损伤侧别、受伤至手术时间、合并软骨及半月板损伤构成比以及术前Lysholm评分、国际膝关节文献委员会（IKDC）评分、疼痛视觉模拟评分（VAS）、胫骨前移差值、Blumensaat角等基线资料比较，差异均无统计学意义（
P
>0.05）。见
表1
。
Comparison of baseline data between the two groups (
n
=30)
两组基线资料比较（
n
=30）
基线资料
Baseline data
I.D.E.A.L组
I.D.E.A.L group
TT组
TT group
统计值
Statistical value
P
值
P
value
性别（男/女，例）
20/10
χ
2
=0.317
0.573
年龄（
x
±
s
，岁）
29.06±7.12
27.84±7.46
t
=0.648
0.520
身体质量指数（
x
±
s
，kg/m²）
20.44±1.31
20.73±1.36
t
=−0.816
0.418
致伤原因（运动伤/其他，例）
19/11
χ
2
=1.270
0.260
损伤侧别（左侧/右侧，例）
12/18
16/14
χ
2
=1.071
0.301
受伤至手术时间（
x
±
s
，d）
10.06±2.80
9.93±3.05
t
=0.176
0.861
合并软骨及半月板损伤 ［例（%）］
7（23.33）
5（16.17）
χ
2
=0.417
0.519
术前Lysholm评分（
x
±
s
，分）
42.2±10.3
43.3±10.4
t
=−0.399
0.691
术前IKDC评分（
x
±
s
，分）
35.9±9.4
35.5±8.2
t
=0.183
0.855
术前VAS评分（
x
±
s
，分）
5.3±1.5
5.5±1.7
t
=−0.328
0.744
术前胫骨前移差值（
x
±
s
，mm）
4.88±0.59
4.91±0.74
t
=−0.180
0.858
术前Blumensaat角（
x
±
s
，°）
18.77±2.40
18.27±2.29
t
=0.825
0.413
a. I.D.E.A.L group Blue line area: “Anatomical” Yellow line area: “Direct insertion” Red line area: “Isometric” Dashed black line area: “Low tension” Green circle: “I.D.E.A.L.” positioning point; b. TT group Red line area: Direct insertion Blue line area: Indirect insertion Green circle: the “over the top” positioning point
记录住院时间以及并发症发生情况，包括术后早期（<1个月；膝关节水肿、麻木、下肢深静脉血栓形成）及远期（>1个月；膝关节僵硬、活动后僵硬、骨关节炎）并发症。术前以及术后1周及1、3、6、12个月定期随访，采用Lysholm评分、IKDC评分及VAS评分评价膝关节功能及疼痛程度。术前及术后12个月，使用Ligs关节韧带数字体查仪（上海逸动医学科技有限公司）测量双膝关节120 N应力下胫骨相对于股骨向前位移差值（胫骨前移差值）。术后12个月MRI观察移植物愈合情况，测量信噪比（signal to noise quotien，SNQ）值以反映其成熟度。SNQ值测量时选取移植物股骨端、中段、胫骨端为关注区域，关注区域面积均为0.2 cm
2
，背景信号选取髌腱前2 cm背景噪声区域。SNQ值计算公式如下：SNQ值=移植物信号强度/背景信号强度−股四头肌腱信号强度/背景信号强度
[
9
]
。同时测量膝关节Blumensaat角，即ACL远端前缘与髁间窝顶部连线之间的夹角。计算胫骨前移差值以及Blumensaat角的手术前后差值（变化值）进行组间比较。
1.5. 统计学方法
采用SPSS27.0统计软件进行分析。计量资料采用Shapiro-Wilk检验进行正态性检验，均符合正态分布，数据以均数±标准差表示，组间比较采用独立样本
t
检验；两组Lysholm评分、IKDC评分及VAS评分多时间点比较采用重复测量方差分析，若不满足球形检验，采用Greenhouse-Geisser法进行校正，同一组别不同时间点间比较采用 Bonferroni 法，同一时间点不同组别间比较采用多因素方差分析。计数资料以率表示，组间比较采用四格表卡方检验。检验水准
α
=0.05。
2. 结果
术后两组切口均Ⅰ期愈合，住院时间组间差异无统计学意义（
P
>0.05）。患者均获随访，随访时间12～18个月，平均14.9个月。术后两组膝关节Lysholm评分、IKDC评分均较术前增加，VAS评分降低。除TT组VAS评分术后1周与术前差异无统计学意义（
P
>0.05）外，其余各评分组内各时间点与术前差异均有统计学意义（
P
<0.05）。术后随时间延长，两组上述指标均呈进一步改善趋势，其中Lysholm评分及VAS评分各时间点间差异均有统计学意义（
P
<0.05）；IKDC评分术后1个月与1周差异有统计学意义（
P
<0.05），其余时间点间差异均无统计学意义（
P
>0.05）。组间比较：术后1周I.D.E.A.L组膝关节Lysholm评分、IKDC评分高于TT组，VAS评分更低，差异均有统计学意义（
P
<0.05）；其余时间点两组间各评分差异均无统计学意义（
P
>0.05）。见
图2
。术后12个月，两组胫骨前移差值均较术前减小，差异有统计学意义（
P
<0.05）；I.D.E.A.L组胫骨前移差值变化值高于TT组，差异有统计学意义（
P
<0.05）。
Change trends of the knee joint function and pain scores in the two groups
术后早期，I.D.E.A.L组发生水肿3例，TT组发生水肿3例、麻木4例、下肢深静脉血栓形成3例；术后远期，I.D.E.A.L组发生膝关节僵硬、骨关节炎各1例，TT组发生膝关节僵硬4例、活动后疼痛2例、骨关节炎5例。I.D.E.A.L组术后早、远期并发症发生率均低于TT组，差异有统计学意义（
P
<0.05）。见
表2
。
Comparison of outcome indicators between the two groups (
n
=30)
两组结局指标比较（
n
=30）
结局指标
Outcome indicator
I.D.E.A.L组
I.D.E.A.L. group
TT组
TT group
效应值（95%
CI
）
Effect value (95%
CI
)
P
值
P
value
住院时间（
x
±
s
，d）
5.50±0.76
5.65±0.85
MD
=–0.153（–0.569，0.262）
0.463
胫骨前移差值变化值（
x
±
s
，mm）
3.48±0.74
2.92±0.93
MD=
0.526（0.128，0.997）
0.012
Blumensaat角变化值（
x
±
s
，°）
9.40±2.53
2.33±2.37
MD
=7.067（5.800，8.330）
<0.001
移植物SNQ值（
x
±
s
）
术后12个月MRI检查示两组膝关节移植物均生存良好，走行及张力无异常，未出现移植物断裂、从骨隧道滑脱等情况。两组Blumensaat角均较术前减小，差异有统计学意义（
P
<0.05），I.D.E.A.L组Blumensaat角变化值高于TT组，差异有统计学意义（
P
<0.05）。I.D.E.A.L组移植物股骨端、中段、胫骨端SNQ值均高于TT组，差异有统计学意义（
P
<0.05）。见
表2
及
图3
、
4
。
A 20-year-old female patient in the TT group, MRI before and after ACL reconstruction of right knee
TT组患者，女，20岁，右膝关节ACL重建手术前后MRI
a. 术前；b. 术后1周；c. 术后12个月
a. Before operation; b. At 1 week after operation; c. At 12 months after operation
本研究中，两组术后膝关节功能评分均较术前增加，术后1周I.D.E.A.L组评分均高于TT组，表明两种技术均能明显改善膝关节功能，但I.D.E.A.L技术术后早期膝关节功能恢复更好，分析原因可能是I.D.E.A.L技术重建的ACL相对于TT技术更符合原生ACL解剖学与生物力学，术后患者适应性好，膝关节周围肌肉力量可以达到更好训练要求，膝关节功能恢复更好。术后1周两组VAS评分均较术前降低，但TT组组内差异无统计学意义（
P
>0.05），且I.D.E.A.L组VAS评分明显低于TT组（
P
<0.05）；结果显示术后早期TT组疼痛程度无明显缓解，I.D.E.A.L组疼痛程度低于TT组，分析原因可能是TT技术制备的股骨隧道内口定位更高，股骨隧道更垂直，所造成的骨质缺损更多，患者疼痛相对明显。
传统膝关节稳定性查体试验（如Lachman试验、前抽屉试验等）结果依赖于查体者经验，对于膝关节胫骨向前位移程度难以精准检测。为此，本研究采用Ligs关节韧带数字体查仪测量胫骨前移差值，使检测结果更精准
[
25
-
26
]
。研究结果显示术后12个月两组胫骨前移差值均较术前减小（
P
<0.05），I.D.E.A.L组胫骨前移差值变化值大于TT组（
P
<0.05），提示术后两组膝关节稳定性均较术前提升，I.D.E.A.L组膝关节稳定性高于TT组。
Blumensaat角是ACL重建术后膝关节稳定性的影响因素，与术后膝关节稳定性成负相关
[
27
-
28
]
。本研究中，术后12个月两组Blumensaat角均较术前减小（
P
<0.05），I.D.E.A.L组Blumensaat角变化值大于TT组（
P
<0.05），间接提示术后I.D.E.A.L组较TT组具有更好的膝关节稳定性，结合上述相关评价指标结果， 进一步明确采用I.D.E.A.L技术行ACL重建在膝关节稳定性恢复方面具有优势。分析原因，TT技术的股骨隧道定位方式通常形成较为垂直的股骨隧道，重建ACL也因此相对垂直，股骨侧足印区位于原生ACL之上
[
29
]
。而I.D.E.A.L技术重建ACL股骨侧足印区位于原生ACL之内，解剖学上优于TT技术，能更好地复刻原生ACL控制膝关节前后位移和旋转位移的功能。
Innovative Talents Training Object of Yunnan Science and Technology Department (202205AD160007)
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